W

e would like to start off by replying to several questions we have received about the Minimum Data Set (MDS) 3.0. First, we can't emphasize enough that the MDS 3.0 is still just a draft. It is still in the planning stage. If you have downloaded a copy of the draft from the Centers for Medicare and Medicaid Services (CMS) website, remember this: It is just a draft. CMS recently announced a "Townhall Meeting," which will take place June 2, 2003, from 12:30 pm to 4:00 pm Eastern Time. Access to this meeting will available to providers and the public by phone. CMS is actively soliciting comments about the draft. The phone number is (877) 357-7851. At the prompt, enter ID# 244453. After entering the ID number, you will be connected.
       At an American Association of Nurse Assessment Coordinators (AANAC) conference in Baltimore this spring, several government officials from CMS presented an update on the MDS 3.0. The new MDS 3.0 is planned for release sometime in the late fall or early winter of 2004. CMS has several goals in mind for the new assessment form. Overall, they want to reduce the number of submissions, clarify some murky areas, allow tracking of pain management, create more accurate tracking of data for the quality indicators (QIs) and quality measures (QMs), standardize several scales related to cognitive impairment, mood indicators, and behavior patterns, and revise the Resident Assessment Protocols (RAPs).
       Here are some highlights of the projected changes:
* Sections AA/AB/AC/AD/A will be combined
* Section A will be the tracking form
* Items AA8a and AA8b will be combined and become A11: Reason for Assessment
* Behavior symptoms will be further divided into wandering; verbally aggressive behavior; physically aggressive behavior; physically nonaggressive behavior; and resists care
* A shorter tool for moods will include standardized questions to be asked directly of the residents
* New functional scales for activities of daily living (ADLs)
* Change in the balance test
* "Stamina" will be added to the functional ability
* An assessment of pain management will be added
* Staging of pressure ulcers only, using National Pressure Ulcer Advisory Panel (NPUAP) language
* RAPs will include more areas.
       The following timetable was also released. It is subject to change.
* February 2003: Stakeholder and State Teleconferences
* March 2003: Award of the Validation Contract
* June 2003: First Town Hall Meeting
* August 2003: MDS 3.0 Validation Test
* January 2004: MDS 3.0 National Validation Test
* April 2004: MDS 3.0 Final Draft Instrument
* August 2004: Second Town Hall Meeting
* December 2004: Final Instrument available.
       In preparing for the MDS 3.0, new technology will be required. CMS is developing crosswalks for the Census and Conditions (672) and Resident Roster (872) forms. A new Grouper will be developed using the current model of Resource Utilization Groups (RUGs). The new form will continue to allow states to customize section S for their own needs. The existing QIs will be rewritten to interconnect with the new form.
       These changes may be why the downloaded draft is causing so much confusion and actual dismay among clinicians. The draft looks more complicated and less friendly, and understanding it is hard without a full explanation of the entries. So again, we advise everyone, you will have a chance to comment on this draft in June. Do not remain among the silent majority. Comment like mad! Keep your eyes open for that phone number. Let CMS know what you like and/or dislike about the draft. One stipulation though--read the draft, think about what CMS is trying to accomplish, and comment accordingly. Now for those questions.
       "Dear Mabel: I don't understand where all the information comes from for the QIs and the QMs. Is it all on the MDS?" (licensed practical nurse, Tennessee)
       Answer: We continue to be surprised at how many in the business do not know where all the information on the QIs and QMs come from. The easy answer is yes, all the information for the QIs and the QMs can only come from MDS assessments. The MDS is the only nationally collected set of uniform data available for analysis of long-term care. But, as we all know, there is never a simple answer with the MDS. Certain assessments, such as the admission assessment, are excluded when calculating the QIs. Also, QIs do not include any of the Prospective Payment System (PPS) assessments unless they are combined with an Omnibus Budget Reconciliation Act (OBRA) assessment. When it comes to QMs though, PPS assessments are used. The QMs for pain and decline in ambulation use PPS assessments. This is one of the many reasons correct coding is so critical. Learn which areas impact the QIs and QMs and ensure the coding for these items is in accordance with the Resident Assessment Instrument (RAI) manual. The state Quality Improvement Organizations, or QIOs, have a wealth of information on this and other matters concerning the QMs.
       "Dear Mabel: We have been getting mail at our facility from someone at a QIO. It seems to have to do with the MDS and QMs. What is it?" (registered nurse, Washington)
       Answer: Good question (especially as it relates to the previous one). We will try to keep the answer simple. Do you remember hearing about PROs? They were Peer Review Organizations. They were state organizations that in the past focused primarily on acute care, i.e., hospitals. They reviewed cases from hospitals in an attempt to act as an overseeing agency and to maintain quality. The focus has changed dramatically in the last two years. The organizations have been renamed Quality Improvement Organizations (QIOs), and their focus is on long-term care. QIOs are part of the Nursing Home Quality Initiative that was implemented by CMS to improve quality care in long-term care facilities. For a more in-depth explanation, go to the following website: http://cms.hhs.gov/quality/nhqi/. When you arrive, look at the left hand side. In that yellow border, you should see "Quality Initiatives" as an option. Double click on it, and you should be able to find your way from there. QIOs are usually medical consulting firms that bid on contracts let by CMS. If they win, they are funded through this contract to conduct quality improvement activities in the area or state on which they bid. Rhode Island is being proclaimed by many government agencies as having the premier QIO. They really have set the standard for QIOs nationwide. Their website is http://www.riqualitypartners.org. Again, we can't emphasize how much knowledge and information these agencies have to share. QIOs are an arm of CMS that is not there to survey, investigate, or scrutinize. They exist to help you understand the QMs and improve them. They can assist you in setting up a quality improvement team for your facility. They have no punitive powers.
       "Dear Mabel: We admitted a resident on a Medicare Part A stay from another facility. Can Medicare Part A coverage be continued in our facility?" (licensed practical nurse, Louisiana)
       Answer: Yes, but again there are some precautions. If the resident meets all the eligibility requirements, then you may continue him or her on Part A Medicare. The admission to your facility must be within 30 days of the discharge from the previous facility. There must be a medical need to cover the resident at a skilled level of care. There must have been a 3-day qualifying hospital stay before the resident was admitted to the previous facility. Check to be sure the other facility had not discontinued the resident from Part A and to see how many days the resident has remaining in the 100 days. Then proceed with your regular PPS schedule of assessments, starting with the 5-day PPS.
       "Dear Mabel: We had a resident go to the hospital for a flap revision of a decubitus ulcer. How do I code for the surgical revision of the pressure area? It started out as a pressure area, but now it is a surgical wound, or anyway it seems so to me. What should I do?" (registered nurse, Mississippi)
       Answer: Since the wound has undergone surgical debridement and a flap procedure, it is now considered a surgical wound and should be coded as such. Please refer to the RAI manual page 3-166, "Surgical Wounds--Includes healing and nonhealing, open or closed surgical incisions, skin grafts or drainage sites on any part of the body." Also refer to page 3-159, under M1, "Definition:...Rashes without open areas, burns, desensitized skin and surgical wounds are NOT coded here, but are included in item M4." So the surgical revision would be coded under M4 at g.
       "Dear Mabel: Our facility admitted a resident for a PPS stay who suffered a stroke after the A3a date for her 5-day PPS assessment. What should I do? Make her 5-day PPS a solo act and do her admission assessment with her 14-day PPS?" (registered nurse, certified, New Jersey)
       Answer: That sure seems like the easiest fix for the problem. We know some facilities have policies to do the admission assessment along with the 5-day PPS, but sometimes you have to be flexible. However, if you have already coded it as an admission and a 5-day PPS, then you will need to do a significant change in status assessment along with the 14-day PPS assessment. If you do this, then you must do RAPs with both assessments.
       Until next issue, we will keep our ears to the ground and our eyes open to keep you posted on what is happening out here in MDS land. Remember, the only constant is change. If you have a question for Mabel, you can e-mail us at MabelMDS@aol.com.